Sexuality is an important aspect of human identity and contributes significantly to the quality of life in women as well as in men (1). Sexual function postpartum is affected by the changes in hormonal milieu, anatomy, and family structure following childbirth. Dyspareunia and other sexual problems such as loss of sex drive in the postpartum period is a well-known problem and frequencies of sexual health problems as high as 30-60% three months postpartum and 17-31% six months postpartum have been reported (2). A large cohort study from Sweden found vaginal or perineal tears, regardless of degree, to be associated with a delay in women’s resumption of sexual intercourse defined as more than 3 months after giving birth (8), while about 10% of primiparous women had not yet resumed sexual intercourse six months postpartum. The causes of sexual health problems are multifactorial and the mechanisms are still not fully understood. Thus sexual health problems remains an unsolved problem for many women. Among other things, anatomical changes caused by vaginal or perineal tears may contribute to dyspareunia and has important effects on both the timing and quality of the resumption of sexual relations during the initial postpartum months. The association between obstetrical risk factors and postpartum sexual function is not yet well described or understood and thus the aim of this study was to investigate the association between degree of perineal tear, sexual function and dyspareunia 12 months postpartum.

The study was a prospective cohort study performed at four Danish hospitals between July 2015 and January 2019.  
Women delivering vaginally, at least 18 years old, able to read and speak Danish were eligible. After the delivery, they were informed about the study. Further information was sent by e-mail and the women were invited by phone to participate in a face-to-face interview including baseline question-naires and a clinical examination comprising a perineal inspection at 16±5 days postpartum. Written informed consent was obtained at baseline. At 12 months postpartum, all participants received the same questionnaires electronically and were invited to a gynaecological examination. All examinations took place at the hospital and participants could bring their baby. 
Baseline data were obtained 2 weeks postpartum by a questionnaire and a clinical examination. Sexual function was evaluated 12 months postpartum by an electronic questionnaire (PISQ-12) and a clinical examination. Primary outcome measures were the total PISQ-12 score and dyspareunia, while exposure variable was the degree of perineal tear. First-degree tears were defined as injury to perineal skin and/or vaginal mucosa. Second-degree tears were de-fined as injury to perineum involving perineal muscles but not the anal sphincter. Third- and fourth-degree tears were defined as injury to perineum involving the anal sphincter complex. Episiotomies were lateral or mediolateral.
To investigate the association between the degree of perineal tear and dyspareuniaor perineal body length, a relative risk regression by use of a generalized linear model with log-link function and bi-nomial distribution as statistical family was performed with estimates reported as relative risks (RR) with 95% confidence intervals (CI). To investigate the association between the degree of perineal tear and sexual health problems measured as the total PISQ-12 score, a linear regression was performed, and results presented as regression coefficients (β) with 95% CI.

A total of 554 primiparous women participated in the study: 191 with no/labia/first-degree tears, 189 with second-degree tears, and 174 with third-/fourth-degree tears. At 12 months postpartum, more than half of the women who sustained anal sphincter tears had dyspareunia compared to one fourth in women with no/labia/first-degree tears. Women with anal sphincter tears had a higher degree of sexual health problems in general. In addition, we found women with perineal body length ≤ 2 cm to be in higher risk of dyspareunia.
Episiotomy was performed in 54 cases and 95 women had an operative vaginal delivery. The proportion of women with dyspareunia was: 25%, 38% and 53% of women with no/labia/first-degree, second-degree or third-/fourth-degree tears, respectively. 
Compared to women with no/labia/first-degree tears, women with second degree or third- or fourth-degree tears had higher risk of dyspareunia (aRR 2.05; 95% CI 1.51-2.78 and aRR 2.09; 95% CI 1.55-2.81, respectively). Women with third- or fourth-degree tears had a higher mean PISQ-12 score (12.2) than women with no/labia/first-degree tears (10.4)

Although sexual problems are common one year after childbirth, especially among women sustaining tears of second-, third- or fourth-degree the proportion of women who ask for help or discuss their problems is low. Thus, it is important to give words to the sexual well-being in the postpartum assessment of women and to put a particular focus on the women in high risk of developing sexual health problems. Further, pregnancy is a time in women’s life when they are in contact with the health services. This provides an opportunity to identify and counsel women with dyspareunia as they are at risk of persistent sexual health problems 12 months postpartum. 
If dyspareunia seem to be caused by vaginal dryness, local vaginal oestrogen or lubricants should be provided. If tender scar tissue is identified, perineal massage or use of lignocaine gel may be helpfull and thus new mothers should be given these advises.

The findings from this cohort study of primiparous women demonstrate that impairment of sexual health is common among primiparous women after vaginal delivery. Women delivering with no tears, tears isolated to the labia or small tears of first-degree reported the best outcomes overall, while more than half of the women with anal sphincter tears were experiencing dyspareunia. It is therefore important to minimize the extent of perineal trauma and to thoroughly counsel women and their partners about sexuality before, during and after pregnancy.

Bossini L, Fortini V, Casolaro I, et al. [Sexual dysfunctions, psychiatric diseases and quality of life: a review]. Psychiatria polska 2014;48(4):715-26. [published Online First: 2014/10/16]
Lagaert L, Weyers S, Van Kerrebroeck H, et al. Postpartum dyspareunia and sexual functioning: a prospective cohort study. The European journal of contraception & reproductive health care : the official journal of the European Society of Contraception 2017;22(3):200-06. doi: 10.1080/13625187.2017.1315938 [published Online First: 2017/04/28]
Radestad I, Olsson A, Nissen E, et al. Tears in the vagina, perineum, sphincter ani, and rectum and first sexual intercourse after childbirth: a nationwide follow-up. Birth (Berkeley, Calif) 2008;35(2):98-106. doi: 10.1111/j.1523-536X.2008.00222.x [published Online First: 2008/05/30]

Continence 2S2 (2022) 100446
DOI: 10.1016/j.cont.2022.100446